Severe Heat Illness

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The Attack One crew is called to stand by for a session at the department’s training academy. The day started off like most spring days, with a cool morning and some fog, but about an hour before the training was to begin, the fog dissipated and temperatures warmed.

The session is a multipurpose one: The department is training on new ladder trucks, a new training tower and self-contained breathing apparatus recently purchased for the agency. The training will involve climbing evolutions and work inside the tower. Multiple crews will go through their paces at the same time, and fresh crews will arrive every two hours to complete the rotations.

The senior members of the Attack One crew are to provide training to junior department colleagues during this session. The crew is responsible for any injuries that occur and for establishing and maintaining a formal incident rehabilitation program. The paramedic member of the Attack One crew is designated as rehab command and will be responsible for the surveillance and rehabilitation functions.

The rehab area is placed close to the training tower. It is initially set up in a sunny area of the training grounds, but soon the crew notices that temperatures are climbing and higher than predicted for the day. They move the rehab area into some shade and ask for cooling equipment to be brought from the storage area where it spent the winter.

The rehab area is initially pretty quiet; the injuries are mostly minor lacerations from the sharp edges of the new equipment. But then some of the firefighters begin to get very warm and come in for cooling and fluids.

One of the trainees notes the screening process seems to rely on something other than traditional teaching on heat-related illnesses: “I’ve noticed our firefighters have all come in with cramping. Some have really red skin, some are pale, and some have normal-looking skin. That doesn’t seem to predict who’s the sickest.”

“That’s correct, and you’ll see this take place the rest of the afternoon,” the paramedic responds. “Many of our members get really bright red skin as they work. Some get cramps. Mental status change is our key symptom. If someone isn’t thinking clearly when they arrive, it’s a serious problem, and we’d head to a hospital. Most of the firefighters do fine with about 15 minutes of cooling and some oral fluids. If they don’t act right and clear quickly, they go to the hospital.”

Initial Assessment

A 45-year-old male, confused and warm to the touch. He was initially reported to be unresponsive but has been speaking since he was removed from the training building.

Primary Survey

Airway: Open.

Breathing: Uncompromised.

Circulation: Poor capillary refill.

Disability: Speaking inappropriately, not oriented to time or place.

Exposure of Other Major Problems: Skin blotched, warm to touch on the head, but extremities cool.

Vital Signs

Time                       HR                          BP                    RR                  Pulse Ox.

1240                      130                     100/palp.               28                       94%

1246                      136                     104/palp.               28                       95%

1253                      142                      96/palp.                24                       92%

Secondary Assessment, Appropriate to Presenting Condition

Head: No trauma.

Neck: No trauma or tenderness.

Chest: Breathing rate increased, clear breath sounds.

Abdomen: Not tender. Patient is nauseated.

Extremities: Moves all four, distal pulses palpable. Skin becomes more blotched.

Neuro: No focal neurologic findings. Moves all four extremities.

AMPLE Assessment

Allergies: None.

Medications: None known.

Past Medical History: Negative.

Last Intake: Breakfast at 0700.

Event: Altered mental status with likely severe heat illness.

The Operation Changes

The training is going well, with members hydrating between evolutions. But then there’s a call for help inside the training building, and the crews scramble to drag out a captain who has collapsed. They bring him to the rehab area and remove his equipment. He’d reportedly passed out in the building but is now speaking, although confused and disoriented. He complains of being chilled.

The members of his crew exit the building and report their engine had a busy morning, working a couple of car fires, and they missed breakfast. The captain had been outside most of the afternoon, and no one could remember seeing him drink anything. He started “acting funny” as they were climbing ladders and moving through the training building, and gave some unusual orders to his crew. He then slumped to the ground.

The Attack One paramedic takes control of the care. He notes the patient’s skin is blotchy, and his pupils are dilated.

“Get an ambulance here immediately,” he quickly directs his crew. “Get a bunch of cold, wet towels and put them on him. Roll him on his side, because he’ll be vomiting soon.

“Command, stop the training. We have a medical emergency and will need to dedicate the rehab crew to the care of this patient. An ambulance is en route, and we’ll be making an emergency removal. When a backup crew can replace us and reopen the rehab area, the training can resume.”

The paramedic asks for another member of the Attack One crew to conduct a focused evaluation of the other members of the captain’s engine crew—if he’s that ill, there’s a risk to them as well. The paramedic then dedicates himself to care of the captain and preparing him for rapid transport. The crew performs continuous surface cooling, provides supplemental oxygen and keeps him on his side as he begins vomiting.

The ambulance arrives, and the captain is rapidly moved to it. The Attack One paramedic accompanies him to the hospital. IV access cannot be obtained, and it’s difficult to get a pulse oximetry reading due to poor perfusion of the skin. The patient’s pulse rate remains around 130, his blood pressure is 100/palpable, and his respiratory rate is around 28 a minute. The three-lead cardiac monitor shows a sinus tachycardia. The patient became unresponsive except to painful stimuli. The air conditioning is on high, and the back of the ambulance gets slippery due to water and ice being used for cooling.

The paramedic directs the ambulance to transport to the regional heart center and calls ahead to notify the emergency department.

Hospital Course

On arrival at the ED, the patient has a rectal temperature of 105ºF despite about 30 minutes of prehospital cooling. The cardiac bypass operating room is opened, and he goes through that process. He’s then placed in the intensive care unit and recovers slowly. His career in the fire service is complete.

Case Discussion

The most serious form of heat illness is often referred to as heatstroke. The most important symptom that differentiates severe heat illness is an altered level of consciousness. The risk factors for severe heat illness are:

• Poor physical fitness/excessive body weight, and those who have had a previous heat-related illness;
• Older age. Persons over 40, even those in relatively good physical condition, have an increased potential for heat illness;
• Medications or street drugs. Many medications and a large number of illegal drugs can impact the body’s temperature-regulating systems and hydration level;
• Lack of heat acclimatization. This means severe heat illnesses often happen in the first few weeks or months after winter weather. By late August or September, most of the United States is acclimatized to hot weather, and severe heat illnesses are rare.

Severe heat illness occurs when the body’s temperature-regulating and cooling mechanisms are not operating normally. The victim’s metabolic systems can run out of control, and the core temperature continues to rise. The earliest signs of heatstroke are in the ability to think clearly. The victim will often get confused or disoriented or act in a way inappropriate for circumstances, such as donning clothes because they feel cold. Some patients get very agitated and violent, similar to a patient having an insulin reaction. The skin temperature may not be warm, and many heatstroke patients appear pale or ashen. A few have the classic red, hot and dry skin and are not sweating. A victim may complain of cramps, throbbing headache, nausea, vomiting and dizziness. In later stages the victim will be unconscious or seizing.

It is difficult to obtain an oral temperaure, as the victim is typically breathing very fast, may be vomiting and will have difficulty holding a thermometer in a closed mouth. The hospital will rely on a rectal temperature to get an accurate reading on heatstroke patients.

Severe heat illness will cause permanent disability or death if emergency care does not begin promptly. Aggressive internal methods of cooling will be needed at a hospital. The victim may be slightly dehydrated, but large volumes of IV fluids are rarely needed and may be dangerous.

External cooling is typically not effective by itself, but it needs to be started in the field:

• Get the victim to a sun-shaded location;
• Remove whatever clothing you can while maintaining modesty;
• Put the victim on his/her side, as most will vomit;
• Cool the victim rapidly using anything available. Spraying with cool water and a fan is effective;
• Use cold compresses (cold/iced towels are most useful) to the forehead, axilla and groin areas;
• If available, immerse the victim in a pool or tub of cool water or a cool shower;
• Do not give the victim large volumes of fluids to drink, as this will likely result in vomiting;
• If it does not delay transport, start an IV and give a small bolus of fluids.

Incident Rehabilitation

NFPA 1584: Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises was instituted in 2008, and the second revision will be published shortly. The standard states, “Procedures shall be in place to ensure that rehabilitation operations commence whenever emergency operations pose the risk of members exceeding a safe level of physical or mental endurance.”

The standard calls for liberal application of rehabilitation services at working incidents and training operations. It is to be applied by organizations providing rescue, fire suppression, emergency medical services, hazardous-materials mitigation, special operations and other emergency services, including public, military, private and industrial fire departments.

NFPA 1584 is to be applied in a broad range of circumstances, so discussions need to include the leadership of local EMS and fire support agencies. Many departments find it helpful to do this planning in tandem with other regional fire and EMS providers so programs have similar elements and consistency in applications, training, equipment and documentation.

The program will need to include a process for implementing rehabilitation operations at all types of incidents and times of day. Separate resources are needed for cold-weather rehab. As demonstrated in this case, a surveillance and rehab program is needed at training exercises and for other physically demanding duties. This will include screening and surveillance programs to protect candidates and department members taking part in these strenuous activities.

Many fire departments work with support EMS agencies. These EMS personnel must be trained and equipped to perform fire rehabilitation services. Programs should include training, equipment, methods of deployment, collection of information, documentation and integration with other critical scene responsibilities. If EMS personnel are to establish and maintain the rehab program, how will that be accomplished at incidents where there are civilian victims? Who provides rehab if a firefighter gets injured and needs to be transported to a hospital? How will rehab crews be utilized and rotated in prolonged incidents?

Some departments have invested in equipment useful for personnel cooling. This may include cooling systems, fans, shades, drink dispensers, icemakers and other equipment that increases the effectiveness of the process. Fluid coolers alone are not sufficient for victim cooling, and Gatorade showers for incident and rehabilitation command officers are rarely utilized.

Learning Point

Incident rehabilitation is an important part of training operations with heavy physical activity. Altered mental status is the key symptom for recognizing patients in serious trouble from a heat-related illness.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.